SAFETY PLANNING AND PROMOTING ADHERENCE TO THE PLAN

Safety planning is a structured and proactive way to help people plan effective strategies, activities and sources of support they can use to help them prevent or manage a developing crisis and keep them safe from self- harm. Suicidal urges fluctuate, so if the person can delay acting on suicidal impulses, it could be lifesaving.

Goodpractice point

Everyone at risk of suicide should have a safety plan with strategies for keeping themselves safe, Reasons for living (RFL) and who to contact for support.

A safety plan should include:

  • • RFL and reasons not to harm themselves, with a gentle request to consider these.
  • • A plan to keep the person’s environment safe, including any agreement to remove or distance from self-harm or suicidal means.
  • • Activities to lift their mood or help to calm them. I don’t encourage distraction as people are usually already over-reliant on this and distraction doesn’t transform mood or mental state. Buying time is a valid goal, as suicidal thoughts fluctuate but ideally this is done with activities in line with values or activities that improve the movement (Linehan 1993) or provide skilful occupation.
  • • People to talk to if distressed. It is important to build a network of support that can be mobilised in the event of a crisis. This might include both personal contacts and third-sector organisations such as the Samaritans. Cole-King et al (2013) suggest a “key contact” from the person’s immediate circle of family and friends should be identified. This needs to be someone the person can trust who can support them and, if helpful, to attend appointments.
  • • Professional support, such as 24-hour crisis telephone lines.
  • • Emergency NHS contact details.
  • • Names and all phone numbers for people to be contacted; personal agreement to use the plan and review it together at intervals.

Stanley and Brown (2008) suggest the following the following principles:

1. Recognising warning signs that are proximal to an impending suicidal crisis

By reflecting back on previous crises, using timelines or chain analysis, we identify warning signs for the client to watch out for. Helpful questions to assist recognition of warning signs include:

“How will you know when you need to start using your safety plan?”

“Looking back, what events, thoughts and feelings have triggered previous suicidal states?”

2. Identifying and employing internal coping strategies without needing to contact another person

a. Identify coping strategies - “what has worked before?”

b. Discuss the likelihood of using such strategies “How likely do you think you would be able to do this during a time of crisis?

c. Identify barriers and problem-solve: “What might prevent you from thinking of or doing these activities or skills?” Problem- solve together to address barriers and discuss alternatives and strategies.

  • 3. Naming people to contact (friends and family) without discussing suicidal thoughts, to optimise social connectedness or belongingness. Consider social settings the person can attend (e.g. church group or place of worship, day centres, gyms, clubs) and identify friends and family members that the service user might feel able to contact to do some activity with. Include contacts for “kindly interaction” (not necessarily confiding their suicidal thoughts). Getting social interaction through an activity can have a double benefit by meeting interpersonal needs and improving mood through behavioural activation.
  • 4. Contact family members or friends who may help to resolve a crisis and with whom suicidality can be discussed. Ideally these will be people who are willing and have agreed to help. The client may, for example, have shared their crisis plan with them. These need to be appropriate adults rather than young carers (as can happen when a young person is supporting a parent with mental health problems or suicidal crises).
  • 5. Contacting mental health professionals

It is helpful to clarify and agree the purpose of this, how long the call is likely to last and what the focus will be. In order to address suicide risk effectively, an unplanned crisis call will typically take 15-30 minutes. As in DBT, it is a good idea to keep these calls short and focused. Don’t simply instruct the patient to contact services (sadly this is common practice). Enquire if they are likely to and, if not, what will get in the way of them contacting services. Discuss their expectations of what will happen and if necessary previous experiences. Crisis or out- of-hours services can have low satisfaction with service users. There are a number of reasons for this such as high staff turnover or inadequate training. It may be helpful to give the patient some context about the crisis service, e.g. how pressured they are so can end up giving out suggestions which can seem unhelpful or too generalised. I often explain that we have staff shortages and may have to rely on less experienced temporary staff. If there is a specific practitioner they do not want to talk to again, it can be helpful to explain the size of the team and ask the patient to estimate the chances of getting that individual again. They may even have avoided contacting the crisis service because of one practitioner they fell out with who in fact left the service. If the person knows DBT skills you can invite them to practise willingness or beginner's mind.

6. Reducing the potential for using lethal means

Discuss and reduce access to means and strategies to reduce risk. Service users should be encouraged to take responsibility for disposing of or handing in means that they are in possession of and are thinking of using to self-harm in the immediate or distant future. It is important to explore ambivalence here; discussing their suicidality is evidence of ambivalence and provides opportunities to look for RFL.

In addition to this I would add that

  • • Ideally a person should write their own safety plan with support, as practised in CAMS (Jobes 2006, 2016) or it can be co-written with a clinician or practitioner. StayingSafe.net has a downloadable blank safety plan template.
  • • The safety plan should be rooted in and informed by your assessment of that individual and their personal formulation of suicidality. For example, Sudak and Rajyalakshmi (2018) suggest patients can be asked to reflect on the things that will be missed if they die, year by year. This can bring to mind the reality of what the patient will miss. However, this would not be a wise suggestion if you had established that the person saw themselves as a burden to their family and friends as thinking about future events could trigger thoughts that the suicidal person would spoil them if they were there.
  • • Target key factors identified from your chain analysis, such as the need to reduce physical arousal or agitation or connect to feeling loved. If someone feels suicidal when problems feel overwhelming, you may want to suggest they write a worry list which they can then break down into manageable steps and just focus on one at a time or seek help in tackling the problems. If they become emotionally dysregulated then recording their feelings in a diary, letter, blog or video could be helpful.
  • • Consider the context of where people are likely to be. Are they living alone? with supportive others? with others who may trigger them? Are they most likely to feel suicidal late at night?
  • • Be sensitive when listing supportive others lest people have limited or even no supportive relationships or people they would trust. If this is the case, then contact with animals and pets can also be very beneficial. I have known clients who even have an important affiliation with someone else s pet if they are unable to have pets themselves.
  • • Always have a small range of agreed options as no one skill works all the time or fits every situation.
  • • Address obstacles. Troubleshoot what stops people seeking help or connecting to others. Consider doing a“hot cross bun”and identifying core beliefs. For example, people may feel they are burden or not know how to ask for help with words. These obstacles can then be addressed in your SFI, by shaping and role-play for example. You can write a script together of how to ask for help; what to say to whom and role-play doing this.
  • • Rather than aiming to write the perfect safety plan in one go, include elements which the client has some experience of working for them and confidence they can help so are likely to use. If this doesn’t apply, then don’t include those elements until and unless the client acquires this with coaching and practice.
  • • Everyone can benefit from having the Samaritans contact details (telephone 116 123). This is especially important for clients who are unlikely to contact professional services. Invite the client to enter this and mental health service numbers into their mobile.

Safety planning is a process, not an end in itself. A common deficiency or error in mental health practice when stafF are under pressure to complete tasks or have high caseloads or throughput of patients is to prescribe a safety plan which the patient may or may not be able or willing to participate in. If you have significant suicidal thoughts and urges, maintaining one’s own safety requires a set of skills which need guidance, fostering, practice, shaping and reviewing. The process of safety planning usually requires “shaping” self-care as well as shaping helpseeking behaviour before or after self-harm. A patient may not follow advice if requested too early within an intervention. Skills often need to be rehearsed and practised in session and then practised with “successive approximation” outside of session, i.e. in their natural environment with all its potential flux and triggers. In session you can use imaginalrehearsal in which you ask the patient again to take you through the sequence of events leading to the most recent episode of suicidal ideation or suicidal self-directed violence. Help your client using the skills you have learnt and practised together to respond cognitively, affectively and behaviourally to take positive steps towards staying alive. If the patient is moving too fast or neglecting important points, pause and ask about alternative ways of thinking, feeling and behaving. Use as much time as needed until the person can demonstrate solid learning of a few key strategies to prevent suicidal behaviour (Table 3.2).

Table 3.2 Creating a safety plan

Element of plan

Sample questions

Warning signs and personal triggers

  • • Are there any specific situations or people that you find stressful or triggering, or that contribute to your suicidal thoughts?
  • • How will you know when your safety plan should be used?
  • • What are some of the difficult thoughts, feelings or behaviours that you experience leading up to a crisis?

Reducing access to means (“making your situation safer"

  • • What things do you have access to that are likely to be used in a suicide attempt?
  • • How can we develop a plan to limit your access to these things to help you stay safe?

Identifying reasons for living

  • • What's the best thing about your life?
  • • What's the most important thing in your life?
  • • Is there anything in your future you are looking forward to?

Internal coping strategies

  • • What can you do on your own if you have suicidal thoughts in the future, to avoid acting on those thoughts?
  • • What has helped you in the past cope with suicidal thoughts?

Social contact

  • • Who helps you to feel good when you spend time with them?
  • • Where can you go and be around other people in a safe environment?

Trusted contacts for assisting with a crisis

  • • Among your friends and family, who do you feel you could talk to when you’re having suicidal thoughts?
  • • Who do you feel you could contact to support you during a suicidal crisis?
  • • Which services or professionals can you turn to for support?

Adapted from Stanley and Brown (2012).

It is important for the person to have a workable means of storing and accessing their safety plan. Mobile phones can help these days. You may want to consider multiple storage and then talk together about practicing accessing it. In addition to a detailed safety plan, you may want to develop a shorter coping card which can reduce suicide risk (Wang et al 2016). A trusted person could also keep a copy of the safety plan.

Sample coping card:

When I feel down I will

put on my trainers and walk outside for at least 10 minutes practise my breathing take a shower and relax

When I have the thought that life isn’t worth living, I will take out and reflect on the things in my Hope Box text SHOUT* to 85258 or phone a friend who cares about me If I’m still struggling, I will phone the mental health service. *Shout is a free confidential 24/7 mental health text support in the UK giveusashout.org

 
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